Combat-related Posttraumatic Stress Disorder Research Articles

Virtual Healing: Militarizing the Psyche in Virtual Reality Exposure Therapy

This article analyzes the use of virtual reality exposure therapy (VRET) to treat combat-related posttraumatic stress disorder. In this therapeutic practice, patients wear a head-mounted virtual reality display and enter a simulation designed to incarnate their triggering memories. VRET visualizes the formerly invisible site of psychotherapy, achieving a medical aspiration that has been pursued since the turn of the twentieth century. This visualization subjects therapy to a mode of surveillance and mediates the conditions in which trauma is processed. In this article, I consider how VRET’s user interfaces produce feelings of agency that reconfigure how power is distributed at the scene of therapy. I situate this novel practice at the intersection of two technological histories: the industrial history of the military-entertainment complex that spawned VRET, and the theoretical history that unites psychoanalysis and computation in their mutual ambition to formalize thought. Contending that neither of these histories can be disarticulated from the violent projects they have sustained, I interrogate the politics of a practice that visualizes and virtualizes psychotherapy, arguing that VRET processes trauma according to a militarized worldview.

Effectiveness of PTSD treatments for military service members and veterans

The core concept of the current review was a description and a discussion of the current situation of treating PTSD among military service members and veterans. This paper is focused solely on combat-related PTSD. It explores guideline recommended interventions for such PTSD, its implication, and efficacy based on the examination of the variety of researches being done around the world.

Facilitating Fear-Based Memory Extinction With Dexamethasone: A Randomized Controlled Trial in Male Veterans With Combat-Related PTSD

Objective: Animal and preliminary human studies have demonstrated that glucocorticoids enhance the extinction of fear memories. Impaired extinction of fear memories is a critical component in the development and maintenance of posttraumatic stress disorder (PTSD). The purpose of this translational study was to determine the effectiveness of pairing a glucocorticoid with trauma memory reactivation as a novel intervention to treat PTSD and to measure the duration of the effect. Method: A total of 54 male veterans with combat-related PTSD in this double-blind, randomized, placebo-controlled trial received either four weekly glucocorticoid (dexamethasone [DEX]) or placebo administrations paired with a 45-second trauma memory reactivation task. PTSD and depressive symptom severity were assessed at baseline and at one three, and six months. Results: Trauma memory activation paired with DEX versus trauma memory activation paired with placebo demonstrated a significantly greater reduction of PTSD symptoms for DEX at the one-month (p = .037) and three-month (p = .036) posttreatment assessments, but the difference was no longer evident at six months. DEX showed a nonsignificantly greater reduction of PTSD symptoms than placebo over the course of the study (p = .067). Significantly more veterans in the DEX group lost their diagnosis of PTSD at one month posttreatment compared to the placebo group, but the difference was not maintained at three or six months. DEX had no effect on depression symptoms. Conclusions: Despite insufficient power to test differences in PTSD symptom reduction, findings suggest that this novel intervention may have potential for treatment of combat-related PTSD.

Does Traumatic Brain Injury Attenuate the Exposure Therapy Process?

Research indicates that exposure therapy is efficacious for combat-related posttraumatic stress disorder (PTSD) comorbid with traumatic brain injury (TBI) as is shown by reduced PTSD treatment outcome scores. What is unknown, however, is whether the process of fear extinction is attenuated in veterans with TBI history. Increased PTSD symptomatology and possible cognitive deficits associated with TBI sequelae may indicate additional or longer exposure sessions to achieve habituation and extinction comparable to individuals without TBI history. As such, a more extensive course of treatment may be necessary to achieve comparable PTSD treatment outcome scores for individuals with TBI history. Using a sample of veterans with combat-related PTSD, some of whom were comorbid for TBI, this study compared process variables considered relevant to successful treatment outcome in exposure therapy. Individuals with and without TBI demonstrated similar rates of fear activation, length and number of exposure sessions, within-session habituation, between-session habituation, and extinction rate; results remained consistent when controlling for differential PTSD symptomatology. Furthermore, results indicated that self-perception of executive dysfunction did not impact the exposure process. Results suggest that individuals with PTSD and TBI history engage successfully and no differently in the exposure therapy process as compared to individuals with PTSD alone. Findings further support exposure therapy as a first-line treatment for combat-related PTSD regardless of TBI history.

Longitudinal Changes in Combat-Related Posttraumatic Stress Disorder Among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans With Hazardous Alcohol Use: The Role of Avoidance Coping.

Military personnel who have experienced combat trauma are at risk for developing posttraumatic stress disorder (PTSD). A greater recognition of the complex array of vulnerability factors that contribute to PTSD severity has led researchers to examine other non-combat-related factors. This longitudinal study examined a number of pre-, peri-, and postdeployment factors hypothesized to contribute to PTSD symptomatology among returning Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans presenting with at least subthreshold PTSD symptoms and hazardous alcohol use in a primary care setting. Purported risk factors included childhood family environment, severity of combat exposure, postdeployment social support, alcohol dependence severity, and an avoidant coping style. At baseline, postdeployment social support and avoidant coping contributed to PTSD severity. Only avoidant coping was associated with changes in PTSD symptom at 1-year follow-up. Reducing avoidant coping may deter the maintenance of PTSD among veterans with PTSD symptoms and hazardous alcohol use.

Psychiatric comorbidity and PTSD-related health problems in war veterans: Cross-sectional study

Background and objectivesPTSD rarely occurs on its own and opinions on the correlation between PTSD and its comorbidities are still divided. MethodsTo identify the comorbidity profile of psychiatric diagnoses in PTSD – affected war veterans and to determine the correlation with mental and health problems. Participants and methodsThe experimental group consisted of 154 war veterans with combat-related PTSD. The control group was made of 77 veterans without PTSD. The study applied a general demographic questionnaire, the Harvard Trauma Questionnaire – Bosnia and Herzegovina version and the MINI. ResultsA 97.4% of PTSD-diagnosed veterans satisfied criteria for other mental disorders and that 44.8% suffered chronic somatic problems. More frequently they suffered from current depressive episode (41.6%), past depressive episode (36.4%), depressive episode with melancholic features (36.4%), dysthymia (13.6%), panic disorder with agoraphobia (11.0%), generalized anxiety disorder (82.5%) alcohol abuse (34.4%) and suicidal ideation (26.0%). ConclusionThe study showed that chronic PTSD in war veterans was almost always accompanied by multiple psychiatric and often somatic comorbidities.

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OBJECTIVES/SPECIFIC AIMS: Cardiovascular disease (CVD) is the leading cause of death among US adults and its prevalence is increasing, despite efforts to identify, and address risk factors. Post-traumatic stress disorder (PTSD) has been identified as a potential risk factor for CVD, though the results to date have focused on male veterans with combat-related PTSD. To our knowledge, there are no prospective analyses/reports among older community-dwelling adults following Hurricane Katrina. The purpose of this study was to explore the link between PTSD associated with Hurricane Katrina and incident CVD among elderly adults using data from the Cohort Study of Medication Adherence among Older Adults (CoSMO). METHODS/STUDY POPULATION: PTSD associated with Katrina and incident CVD events were assessed among 2075 hypertensive participants age ≥65 who were enrolled in a managed care organization in southeastern Louisiana. Baseline surveys were conducted between August 2006 and September 2007. Baseline surveys were conducted between August 2006 and September 2007. PTSD was assessed using the civilian PTSD CheckList (PCL-17) and 2 cut-off points, ≥37 and ≥44, for primary and secondary analyses, respectively. Participants were followed through February 2011 for a composite CVD outcome of MI, stroke, CHF, or CVD death. Multivariable logistic regression was performed with 13 covariates identified in bivariate analysis: age, sex, race, marital status, education, hypertension knowledge, comorbidities, number of antihypertensive medication classes, dissatisfaction with healthcare, reduced medications due to cost, number of visits to healthcare provider in last year, depression, and coping. RESULTS/ANTICIPATED RESULTS: Participants were 59.8% female and 30.4% black, with a mean age of 75 years. The prevalence of PTSD using the primary and secondary cut points was 6.1% and 4.2%, respectively. In total, 240 (11.5%) participants had a CVD event during a median 3.8 year follow-up. After multivariable adjustment, the odds ratios and 95% confidence intervals (CI) for CVD event for the primary and secondary analyses were 1.90 (95% CI: 1.17, 3.09) and 3.74 (95% CI: 2.05, 6.81), respectively. DISCUSSION/SIGNIFICANCE OF IMPACT: PTSD was associated with an increased risk of incident CVD events among elderly adults. This finding from a prospective cohort study supports earlier reports suggesting PTSD is an independent risk factor for CVD. To our knowledge, this association has not been previously reported among a cohort of elderly community-dwelling adults. This study included hypertensive, elderly, insured participants living in southeastern Louisiana following Hurricane Katrina and may not be generalizable to all people with PTSD. Strengths of this study include its longitudinal design, the identification of incident CVD, the diversity of the study population with respect to gender, race and CV risk, and reduced confounding due to access to care and insurance status. Future research is needed to confirm this finding in other populations and to assess if efforts to minimize the impact of PTSD following disasters reduce CVD risk and premature CVD events among older adults.

Adverse childhood experiences and risk for suicidal behavior in male Iraq and Afghanistan veterans seeking PTSD treatment.

Adverse childhood experiences (ACEs) are associated with increased risk for suicide and appear to occur in disproportionately high rates among men who served in the U.S. military. However, research has yet to examine a comprehensive range of ACEs among Iraq/Afghanistan veterans with combat-related posttraumatic stress disorder (PTSD) or whether these premilitary stressors may contribute to suicidal behavior in this highly vulnerable population. A sample of 217 men entering a residential program for combat-related PTSD completed measures for ACEs, combat exposure, and lifetime suicidal ideation and attempts. The majority of patients had experienced multiple types of adversity or traumas during childhood/adolescence. In particular, 83.4% endorsed at least 1 ACE category and 41.5% reported experiencing 4 or more ACEs. When accounting for effects of deployment-related stressors, we further found that accumulation of ACEs was uniquely linked with thoughts of suicide or attempts among these patients. Namely, for every 1-point increase on the ACE Questionnaire, veterans' risk of suicidal ideation and attempts increased by 23% and 24%, respectively. This brief report provides initial evidence that veterans seeking treatment for combat-related PTSD often have extensive histories of premilitary stressors that may increase suicide risk beyond probable deployment-related traumas. (PsycINFO Database Record

Increased circulating blood cell counts in combat-related PTSD: Associations with inflammation and PTSD severity

Inflammation is reported in post-traumatic stress disorder (PTSD). Few studies have investigated circulating blood cells that may contribute to inflammation. We assessed circulating platelets, white blood cells (WBC) and red blood cells (RBC) in PTSD and assessed their relationship to inflammation and symptom severity. One-hundred and sixty-three male combat-exposed veterans (82 PTSD, 81 non-PTSD) had blood assessed for platelets, WBC, and RBC. Data were correlated with symptom severity and inflammation. All cell counts were significantly elevated in PTSD. There were small mediation effects of BMI and smoking on these relationships. After adjusting for these, the differences in WBC and RBC remained significant, while platelet count was at trend level. In all subjects, all of the cell counts correlated significantly with inflammation. Platelet count correlated with inflammation only in the PTSD subjects. Platelet count, but none of the other cell counts, was directly correlated with PTSD severity ratings in the PTSD group. Combat PTSD is associated with elevations in RBC, WBC, and platelets. Dysregulation of all three major lineages of hematopoietic cells in PTSD, as well as their significant correlation with inflammation, suggest clinical significance of these changes.

Trauma management therapy with virtual-reality augmented exposure therapy for combat-related PTSD: A randomized controlled trial

Virtual reality exposure therapy (VRET) realistically incorporates traumatic cues into exposure therapy and holds promise in the treatment of combat-related posttraumatic stress disorder (PTSD). In a randomized controlled trial of 92 Iraq and Afghanistan veterans and active duty military personnel with combat-related PTSD, we compared the efficacy of Trauma Management Therapy (TMT; VRET plus a group treatment for anger, depression, and social isolation) to VRET plus a psychoeducation control condition. Efficacy was evaluated at mid- and post-treatment, and at 3- and 6-month follow-up. Consistent with our hypothesis, VRET resulted in significant decreases on the Clinician Administered PTSD Scale and the PTSD Checklist-Military version for both groups. Also consistent with our hypothesis, significant decreases in social isolation occurred only for those participants who received the TMT group component. There were significant decreases for depression and anger for both groups, although these occurred after VRET and before group treatment. All treatment gains were maintained six-months later. Although not part of the original hypotheses, sleep was not improved by either intervention and remained problematic. The results support the use of VRET as an efficacious treatment for combat-related PTSD, but suggest that VRET alone does not result in optimal treatment outcomes across domains associated with PTSD.

Apolipoprotein E variants and genetic susceptibility to combat-related post-traumatic stress disorder: a meta-analysis.

Apolipoprotein E (APOE) has recently been studied as a risk factor for association with developing combat-related post-traumatic stress disorder (PTSD) in the military population. These studies have yielded inconsistent findings. The present study carried out a meta-analysis to establish whether the APOE polymorphism confers increased susceptibility to combat-related PTSD. PubMed, Medline, Embase, PsycInfo, and Google Scholar were searched for potential publications relating to patients with PTSD in military settings with combat exposure. Studies provided proper PTSD screening and genotype data on APOE gene variants were all considered for selection in the review. A random-effect model was used to calculate the pooled effect size (Cohen's d) and summary statistics. Sensitivity analyses and meta-regression were used to assess the between-study heterogeneity. Egger's test and rank-correlation test were also carried out to evaluate any potential publication bias. Our study showed a significant association between the APOE e4 gene variant and increased risk for developing combat-related PTSD, with an overall effect size of d equal to 0.28 (95% confidence interval: 0.10-0.45) for e4 carriers versus noncarriers. In contrast, no statistically significant association was found for the APOE e2 variant (d=0.59; 95% confidence interval: -0.29-1.47). The current meta-analysis provides corroborating evidence that supports the fact that the presence of the APOE e4 polymorphism confers greater susceptibility to combat-related PTSD. Future studies with a larger sample size and better consistency in reporting standards are warranted to further evaluate these associations.

Individual variation in plasma oxytocin and vasopressin levels in relation to the development of combat-related PTSD in a large military cohort

In an attempt to decrease the risk of developing mental health problems after military deployment, it is important to find biological markers to identify those at risk. Oxytocin (OT) and arginine vasopressin (AVP) are potential biomarkers for the development of posttraumatic stress disorder (PTSD) because they are involved in the regulation of stress and anxiety. Therefore, the aim was to examine whether plasma OT (pOT) and AVP (pAVP) levels before and after deployment are biomarkers for the development of posttraumatic stress symptoms over time in addition to other known risk factors. This study is part of a large prospective cohort study on candidate markers for stress-related mental health symptoms and resiliency after deployment to a combat zone; Prospective Research in Stress-related Military Operations (PRISMO; N = 907). Data was collected prior to deployment and follow-ups were performed at 1 and 6 months, and 1, 2, and 5 years post-deployment. Blood samples were collected in the first three assessments. The levels of pOT and pAVP were not significantly related to the development of PTSD symptoms over time. The results confirm that age, the experience of early life trauma, combat-related stressors and the presence of depressive symptoms are predictive for the development of PTSD symptoms over time. These findings showed that peripherally measured OT and AVP currently do not qualify as useful susceptibility biomarkers for the development of PTSD symptoms over time in military men after combat.

Skin Conductance Reactivity to Standardized Virtual Reality Combat Scenes in Veterans with PTSD.

Interest in virtual reality (VR) as a clinical tool to augment posttraumatic stress (PTSD) treatment has grown substantially in recent years due to advances in VR technology. Moreover, its potential assisted use in the PTSD diagnostic process has been recognized. In this study we examined physiological responding, skin conductance, to a standardized presentation of non-personalized combat-related VR events (e.g. encountering enemy fire; explosions) as compared to non-combat classroom VR events in 19 Veterans with and 24 Veterans without combat-related PTSD who had been deployed to Iraq and Afghanistan. Veterans watched a total of 12 VR scenarios-six combat-related and six non-combat-related-with each scenario gradually increasing in emotional intensity by adding more VR events in addition to repeating prior VR events. Results show that Veterans with PTSD displayed larger skin conductance reactivity across VR combat events, but not for non-combat VR events, as compared to combat Veterans without PTSD. Nevertheless, Veterans with and without PTSD showed a similar reduction of emotional arousal to repeated presentation of the same VR combat events. Within the PTSD sample, the elevated level of VR combat-related arousal correlated marginally with severity of hyperarousal symptoms. This study confirms that the use of a non-personalized and standardized VR presentation successfully distinguishes Veterans with PTSD from those without on a measure of psychophysiological arousal to combat-related VR stimuli. The assessment of physiological reactivity during the repeated presentation of standardized, trauma-related VR events highlights its use for PTSD assessment as well as treatment.

Baroreflex dysfunction and augmented sympathetic nerve responses during mental stress in veterans with post-traumatic stress disorder.

Patients with post-traumatic stress disorder (PTSD) are at a significantly higher risk of developing hypertension and cardiovascular disease. The mechanisms underlying this increased risk are not known. Studies have suggested that PTSD patients have an overactive sympathetic nervous system (SNS) that could contribute to cardiovascular risk; however, sympathetic function has not previously been rigorously evaluated in PTSD patients. Using direct measurements of sympathetic nerve activity and pharmacological manipulation of blood pressure, we show that veterans with PTSD have augmented SNS and haemodynamic reactivity during both combat-related and non-combat related mental stress, impaired sympathetic and cardiovagal baroreflex sensitivity, and increased inflammation. Identifying the mechanisms contributing to increased cardiovascular (CV) risk in PTSD will pave the way for developing interventions to improve sympathetic function and reduce CV risk in these patients. Post-traumatic stress disorder (PTSD) is associated with increased cardiovascular (CV) risk. We tested the hypothesis that PTSD patients have augmented sympathetic nervous system (SNS) and haemodynamic reactivity during mental stress, as well as impaired arterial baroreflex sensitivity (BRS). Fourteen otherwise healthy Veterans with combat-related PTSD were compared with 14 matched Controls without PTSD. Muscle sympathetic nerve activity (MSNA), continuous blood pressure (BP) and electrocardiography were measured at baseline, as well as during two types of mental stress: combat-related mental stress using virtual reality combat exposure (VRCE) and non-combat related stress using mental arithmetic (MA). A cold pressor test (CPT) was administered for comparison. BRS was tested using pharmacological manipulation of BP via the Modified Oxford technique at rest and during VRCE. Blood samples were analysed for inflammatory biomarkers. Baseline characteristics, MSNA and haemodynamics were similar between the groups. In PTSD vs. Controls, MSNA (+8.2±1.0vs. +1.2±1.3burstsmin-1 , P<0.001) and heart rate responses (+3.2±1.1vs. -2.3±1.0beatsmin-1 , P=0.003) were significantly augmented during VRCE. Similarly, in PTSD vs. Controls, MSNA (+21.0±2.6vs. +6.7±1.5burstsmin-1 , P<0.001) and diastolic BP responses (+6.3±1.0vs. +3.5±1.0mmHg, P=0.011) were significantly augmented during MA but not during CPT (P=not significant). In the PTSD group, sympathetic BRS (-1.2±0.2vs. -2.0±0.3burst incidencemmHg-1 , P=0.026) and cardiovagal BRS (9.5±1.4vs. 23.6±4.3msmmHg-1 , P=0.008) were significantly blunted at rest. PTSD patients had significantly higher highly sensitive-C-reactive protein levels compared to Controls (2.1±0.4vs. 1.0±0.3mgL-1 , P=0.047). Augmented SNS and haemodynamic responses to mental stress, bluntedBRS and inflammation may contribute to an increased CV risk in PTSD.

The loss of a fellow service member: Complicated grief in post-9/11 service members and veterans with combat-related posttraumatic stress disorder.

Bereavement is a potent and highly prevalent stressor among service members and veterans. However, the psychological consequences of bereavement, including complicated grief (CG), have been minimally examined. Loss was assessed in 204 post-9/11, when service members and veterans with combat-related posttraumatic stress disorder (PTSD) took part in a multicenter treatment study. Those who reported the loss of an important person completed the inventory of complicated grief (ICG; n = 160). Over three quarters (79.41%) of the sample reported an important lifetime loss, with close to half (47.06%) reporting the loss of a fellow service member (FSM). The prevalence of CG was 24.75% overall, and nearly one third (31.25%) among the bereaved. CG was more prevalent among veterans who lost a fellow service member (FSM) (41.05%, n = 39) compared to those bereaved who did not (16.92%, n = 11; OR = 3.41, 95% CI: 1.59, 7.36). CG was associated with significantly greater PTSD severity, functional impairment, trauma-related guilt, and lifetime suicide attempts. Complicated grief was prevalent and associated with adverse psychosocial outcomes in veterans and service members with combat-related PTSD. Clinicians working with this population should inquire about bereavement, including loss of a FSM, and screen for CG. Additional research examining CG in this population is needed.

An intensive outpatient treatment program for combat-related PTSD: Trauma Management Therapy.

An estimated 18.5% of veterans returning from Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn are suffering from posttraumatic stress or posttraumatic stress disorder (PTSD). The number of veterans and service duty personnel requesting VA health care services is increasing, and the VA's ability to handle requests is dwindling. Thus, both the content of interventions and the format by which these services are delivered need to be reconceptualized. The authors present a multicomponent intervention program known as Trauma Management Therapy (TMT), a comprehensive, empirically supported treatment that can be delivered in an intensive, 3-week outpatient format. TMT combines individual exposure therapy with group social and emotional rehabilitation skills training to address specific aspects of the combat-related PTSD syndrome. The authors present the format of this novel intensive outpatient program, describe the components, and address implementation factors such as treatment compliance, dropout rates, and administrative considerations.

The efficacy of Trauma Management Therapy: A controlled pilot investigation of a three-week intensive outpatient program for combat-related PTSD

Despite the 8–18.5% of returning Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn (OND) veterans who are suffering from posttraumatic stress disorder (PTSD), few receive empirically supported treatments. Among those that do, the dropout rate is high and more than 50% retain their diagnosis after treatment. This study evaluated the efficacy of Trauma Management Therapy (TMT), delivered in a 3-week intensive outpatient (IOP) format. TMT combines virtual-reality augmented individual exposure therapy with a group intervention to address social isolation, anger, and depression. One hundred twelve (112) OIF/OEF/OND veterans and active duty personnel participated. Assessment included measures of PTSD, sleep, depression, anger, guilt, and social isolation, administered at post-treatment, 3-month, and 6-month follow-up. The effect size for TMT delivered in an IOP format was 2.06, with 65.9% no longer meeting diagnostic criteria for PTSD. There were similar positive effects in other domains and treatment gains were maintained at 6-month follow-up. The results are discussed regarding the need for efficacious, multi-component interventions that can be delivered safely and rapidly, and the potential of this approach towards that end.

Understanding Combat-Related PTSD Symptom Expression Through Index Trauma and Military Culture: Case Studies of Filipino Soldiers.

Few studies demonstrate how the index trauma may influence subsequent post-traumatic stress disorder (PTSD) symptoms, especially among soldiers. There is still no consensus on specific trauma types and their corresponding PTSD symptom profiles. Furthermore, varied PTSD symptom manifestations that may yield to PTSD trauma subtypes are yet to be known. Importantly, the significance of the military culture's possible influence on soldiers' PTSD has also been underexplored. And the dominant PTSD construct may possibly be unable to capture the essential aspects of the military context in understanding combat-related PTSD. Hence, this study aims to reach an understanding into how index trauma and military culture may possibly shape participants' PTSD expressions. Case study design was used, wherein multiple sources of data-such as PTSD assessments, and interviews with the participants and key informants-enabled data triangulation. The three case reports are the outcomes of the corroboration of evidences that reveal an enriched and holistic understanding of the phenomenon under study. The Ethics Review Board Committee of the Armed Forces of the Philippines Medical Center approved the study. The participants were three Filipino active duty combat soldiers. Although all participants had similar index traumas, their PTSD symptom expressions are unique from one another, in that they differ in terms of their most incapacitating PTSD symptoms and other symptoms that have been potentially shaped by military culture. Their most incapacitating symptoms: hypervigilance (case 1), negative belief in oneself and negative emotions (case 2), prolonged distress, and marked physiological reactions to trauma-related cues (case 3), may be understood in the light of how they personally experienced different circumstances of their index traumas. The way participants have anchored specific components of their sworn soldier's creed (i.e., not leaving a fallen comrade) into some of their PTSD symptoms (i.e., feeling guilty for the comrade's death) may be understood in the light of their military culture and how they were personally traumatized by the details of their index traumas. The participants' index trauma and military culture potentially shaped their PTSD symptom expressions that were distinct from one another. The details of the index trauma, including the level of exposure and proximity; and the salience of military culture, such as the soldier's creed, are important elements into understanding how participants experience their PTSD. Limitations of the study include findings that do not give causal interpretations, use of self-report measures, retrospective accounts from interviews, and participants who are all Filipino active soldiers and enlisted army military personnel. Nevertheless, the study provides an enriched and holistic understanding of personal experiences of soldiers with combat-related PTSD. The findings may inform tailored treatments to soldiers whose experiences may be similar to the settings and concepts discovered in the study. Possible clinical and treatment implications were provided in the study. Future researchers may explore on: possible existence of PTSD subtypes within combat-related PTSD category, other facets of military culture that may mitigate or influence PTSD symptoms, and potential roles of index trauma and military culture using national representative samples.

709. Increased Circulating Blood Cell Counts in Combat-Related PTSD: Associations with Inflammation and Symptom Severity

709. Increased Circulating Blood Cell Counts in Combat-Related PTSD: Associations with Inflammation and Symptom Severity

Pre-treatment cortisol awakening response predicts symptom reduction in posttraumatic stress disorder after treatment

Dysfunction of the HPA-axis has frequently been found in the aftermath of trauma exposure with or without PTSD. Decreasing HPA-axis reactivity to different stress cues has been reported during PTSD treatment. The cortisol awakening response (CARi) is a well-validated, standardized measure of HPA-axis reactivity which can be easily acquired in the clinical setting. Whether CARi changes over time in traumatized individuals are specific to PTSD treatment is unknown. Furthermore, a possible role for the baseline CARi in predicting symptom reduction after treatment in PTSD has not been examined before. To answer these questions, a cohort study was conducted in which the awakening cortisol was measured in both PTSD (N=41) and non-PTSD (N=25) combat-exposed male subjects. Measurements took place at inclusion and 6–8 months after inclusion for both the PTSD and the non-PTSD group. During the 6–8 months interval, PTSD patients received trauma-focused focused psychotherapy, whereas non-PTSD patients received no treatment. We found a decrease in the CARi over time in both groups, suggesting it was not specific to PTSD or the effect of treatment. Therefore, caution is warranted when attributing diminished HPA-axis reactivity over time to effects of PTSD treatment. Second, CARi prior to treatment predicted PTSD symptom reduction (CAPS score change) after treatment, and accounted for 10% of the variance, even when adjusted for changes in depressive symptoms and medication use during the study period. A putative role emerges for CARi as a predictive biomarker of symptom reduction in male individuals with combat-related PTSD.